Discuss the principles of
management of a 50 year old
nurse with a 2cm ulcer on the
upper outer quadrant of the
right breast
Dr okpako Isaac oghenero.
MBBS, MWCS, aFMCS
13/09/2019

Outline
• Introduction
• epidemiology
• Statement of surgical importance
• Brief anatomy of the breast
• Peculiarities
• Provisional diagnosis
• Differentials
• Principle of Management
• History
• Examination
• Investigation
• Counselling
• Treatment
• Follow up
• Conclusion
• References

Introduction
• Breast ulcer is a breach in the continuity of the skin of the breast
• Various pathologies such as breast carcinoma, chronic mastitis
tuberculosis among others can cause breast ulcer
• The above 50 year old nurse with an ulcer on the upper outer
quadrant of the right breast is likely having breast carcinoma

Epidemiology
• Breast cancer is the commonest malignancies affecting women
accounting 18.4% of cancers in female world wide
• It is estimated that 1 in 8 Caucasian women (one in 14 blacks) in the
USA and 1 in 12 in Britain will develop cancer of the breast in their
lifetime and the incidence is rising.
• In Nigeria, it is currently the commonest malignancy in Ibadan.

Statement of surgical importance
• Ulcers by themselves is not a diagnosis they are pointers to an
underlying sinister pathology which should be looked out for and
properly treated

Brief anatomy
• There are a pair of breast
located on the anterior thoracic
wall for both male and female

Peculiarities
• Age
• Occupation
• Location of the lesion
• 2cm ulcer

Provincial diagnosis
• Advanced breast carcinoma (T4)

Differentials
• Tuberculosis of the breast
• Chronic mastitis
• Cystosarcoma phylloides
• Squamous cell carcinoma
• Basal cell carcinoma
• Traumatic
• Breast lymphoma
• Metastasis to the breast
• Others

Principle of management of
index case

Principles of management
• Focused history
• Proper physical examination
• Relevant Investigation
• Principles of treatment

Principles of management
• Focused History
• Characteristics of the ulcer
• Complications of the ulcer
• Underlying breast pathology
• History of aetiology
• Systemic manifestations of background pathology
• General clinical state

Principles of management
• Focused History
• Characteristics of the ulcer
• Duration of symptoms
• How was the ulcer noticed
• Rate of increase of the ulcer

Principles of management
• Focused History
• Complication of the ulcer
• Bleeding from the ulcer
• Discharge from ulcer
• Associated pain and character of the pain
• Fever and character of fever
• Anaemia
• Weight loss
• Depression

Principles of management
• Focused History
• Underlying breast pathology
• Associated
• skin changes
• nipple changes
• nipple discharge
• other ulcers in contralateral breast

Principles of management
• Focused History
• History of aetiology
• History of
• prior trauma
• prior swelling in the breast
• menarche parity first and last child birth
• breastfeeding
• OCP and duration

Principles of management
• History of aetiology
• History of
• HRT
• Family history of CA ()
• Irradiation
• Smoking and alcohol consumption
• other ulcers in the body
• Associated other swellings in the body (torso etc)
• History of
• ingestion of unpasteurized milk
• breast piercing by braches of tress or stumps

Principles of management
• Focused History
• Systemic manifestations of background pathology
• History of cough and character of cough, chest pain and
breathlessness
• History of bone pain and change of gait
• History of jaundice abdominal pain loss of appetite
• History of headache change in mental status and convulsion

Principles of management
• Proper physical Examination
• General clinical state
• Characteristics of the ulcers
• Underlying breast pathology
• Systemic manifestation of the underling disease

Principles of management
• Proper physical Examination
• General clinical state
• Appearance
• pallor
• Jaundice
• Level of hydration

Principles of management
• Proper physical Examination
• Underlying breast pathology and Characteristics of the ulcers
• Examination of the breast contralateral and then the pathological
breast
• Examine the ulcer (smell, discharge, position size, shape, edge, floor,
base, surrounding skin)

Principles of management
• Proper physical Examination
• Systemic manifestation of the underling disease
• Cvs: PR, BP, HS
• Chest: RR, orientation of chest, breath sound, added sound, crepitation
• Abd: distension, tenderness, masses
• RE: masses
• CNS: sensorium, sensation
• MSS: bone pain, muscle bulk, power,

Principles of management
• Provisional diagnosis
• Counselling

Principles of management
• Relevant Investigation
• Principle of investigation
• To make diagnosis
• Extent of diseases
• To prepare the individual for treatment
• To make diagnosis
• M/c/s
• Biopsy for:
• Histology
• Immunihistochemistry: ER, PR, HER-2 gene BRACA 1
• FISH
• Sputum AFB
• Zehiel nelson staining
• Lowenstein - Jenson medium
• Gene expert

Principles of management
• Relevant Investigation
• Extent of diseases
• USS: contralateral breast, Abdomen;
(masses, cyst)
• Mammography
• Chest X-ray: pleural effusion cannon
ball appearance
• Spine and pelvic and skull x-ray
• Skeletal scintigraphy
• MRI
• CT scan of the brain and abdomen
• PET CT
• LFT

Principles of management
• Relevant Investigation
• To prepare the individual for treatment
• FBC
• e/u/Cr
• GxM
• ECG
• ECHO
• Adequate counselling
• Goals of treatment
• prognosis

Principles of management
• Treatment
• Breast CA: stage of the tumour
• Principles of treatment
• Local regional therapy
• Surgery
• Mastectomy
• Radiotherapy
• Systemic therapy
• Chemotherapy
• Neoadjuvant
• Adjuvant
• Hormonal therapy
• Tumour specific therapy
• Immunotherapy

Principles of management
• Treatment
• Tuberculosis of the breast: antiTB medication and wound dressing
• Cystosarcoma phylloides: wide local excision for beingn tumour, fro
borderline lesion total mastectomy is done

Principles of management
• Treatment
• Breast lymphoma
• Chemotherapy
• Metastasis to the breast
• Chemotherapy sensitive to the primary tumour
• Surgery of the primary tumour
• Wide local excision

Principles of management
• Follow up
• Weekly
• Three weekly
• Monthly
• Yearly

Conclusion
Detailed history, examination investigation are a prerequisite necessary
for proper diagnosis and consequently appropriate treatment for a
more sinister pathology which may be presenting as a mild disease
such as a 2cm ulcer

Thank you

References
• Badoe and Jaja- Principle and practice of surgery including pathology
in the tropics, 4th edition, PG 94-108.
• Schwartz principles of surgery, 10th edition, Ed F. Charles Brunicardi.
Shock, PG 100-124.
• Bailey and Love’s short practice of surgery, 26th Edition, Shock, PG 13-
23.